Motivational Interviewing: Basic Training Alan Lyme, MSW

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Motivational InterviewingBasic Training

• Alan Lyme, MSW, ICADC, ICCS,
• SBIRT MI Clinical Supervisor
• Medical Center of Central Georgia
• lyme.alan_at_mccg.org
• alanlyme_at_yahoo.com

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MOTIVATIONAL INTERVIEWINGDEFINITION SPIRIT

• DEFINITION Motivational interviewing is a
  client-centered, evidence- based,
  goal-oriented method for enhancing intrinsic
  motivation to change by exploring and
  resolving ambivalence with the
  individual.
• SPIRIT Collaboration autonomy respect
  compassion

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A client-centered, goal oriented intervention
focused on resolving ambivalence in the direction
of change

• not a series of techniques but a way of being
  with clients

(Information on MI adapted from Motivational
Interviewing. Miller and Rollnick, 1991)
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Why Motivational Interviewing?

• Evidence-based gt170 clinical trials
• Effective in reducing maladaptive behaviors
  (e.g., problem drinking, gambling, HIV risk
  behaviors, smoking)
• Effective in promoting adaptive health behavior
  change (e.g., exercise, diet, medication
  adherence)

Miller Rose, 2009 Lai DTC, Cahill K, Qin Y,
Tang J-L, 2010
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Motivational InterviewingUNDERLYING ASSUMPTIONS

• Acceptance
• Autonomy/Choice
• Less is better
• Elicit versus Impart
• Michelangelo Belief
• Ambivalence is normal
• Care-frontation
• Change talk
• Righting reflex

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Eight Stages in Learning MI

• 1. The spirit of MI
• 2. OARS Client-centered counseling skills
• 3. Recognizing and reinforcing change talk
• Eliciting and strengthening change talk
• Rolling with resistance
• 6. Developing a change plan
• 7. Consolidating client commitment
• 8. Shifting flexibly between MI and other
  methods
• Miller, W. R., Moyers, T. B. Eight stages in
  learning motivational interviewing. Journal of
  Teaching in the Addictions.

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FIVE GENERAL PRINCIPLES

• Express Empathy
• Develop Discrepancy
• Avoid Arguments, Right positions
• Support Self-efficacy
• Roll with the Resistance

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OARS

• O open-ended questions
• A affirm, notice the strengths of the
  person, see the motivation in what they dohear
  their values
• R reflection, use empathy, simple and complex,
  2 to 1 statements to questions
• S summarize (5-15 minutes in time together)

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Closed Questions

• Have a short answer (like Yes/No)
• Did you drink this week?
• Ask for specific information
• What is your address?
• Might be multiple choice
• What do you plan to do Quit, cut down, or keep
  on smoking?
• They limit the clients answer options

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Open Questions

• Open the door, encourage the client to talk
• Do not invite a short answer
• Leave broad latitude for how to respond

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Open-ended Questions

• How can I help you?
• Would you tell me about ___?
• How would you like things to be different?
• What are the positive things and what are the
  less good things about ___?
• What will you lose if you give up ___?
• What have you tried before?
• What do you want to do next?

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Closed Versus Open-Ended Questions

• Do you feel you have a problem with alcohol?
• Is it important to you to complete this program
  successfully?
• Anything else?

• What problems has your alcohol use caused you?
  
• How important is it for you to complete this
  program successfully?
• What else?

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Some Guidelines with Questions

• Ask fewer questions!
• Dont ask three questions in a row
• Ask more open than closed questions
• Offer two reflections for each question asked

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Affirmations

• Emphasize a strength
• Notice and appreciate a positive action
• Should be genuine
• Express positive regard and caring
• Strengthen therapeutic relationship

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Affirmations Include

• Commenting positively on an attribute
• Youre a strong person, a real survivor.
• A statement of appreciation
• I appreciate your openness and honesty today.
• Catch the person doing something right
• Thanks for coming in today!
• A compliment
• I like the way you said that.
• An expression of hope, caring, or support
• I hope this weekend goes well for you!

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Reflective Listening
Reflective Listening is the key to this work.
The best motivational advice we can give you is
to listen carefully to your clients. They will
tell you what has worked and what hasnt. What
moved them forward and shifted them backward.
Whenever you are in doubt about what to do,
listen(Miller Rollnick, 1991)
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Types of Empathic Reflections

• Simple/Repeating - Reflect what is said
• Simple/Rephrasing Slightly alter
• Amplified - Add intensity to idea/values
• Double Sided - Reflect ambivalence
• Metaphor - Create a picture
• Shifting Focus - Change the focus
• Reframing - Offer new meaning
• Emphasize personal choice
• Siding with the negative (paradoxical)

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Repeating This is the simplest form of
reflection, often used to diffuse resistance

• Patient I don't want to quit smoking.
• HCP You don't want to quit smoking.

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Rephrasing Slightly alter what the client
says in order to provide the client with a
different point of view. This can help move the
client forward.

• Client I really want to quit smoking.
• HCP Quitting smoking is very important to you.

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Amplified reflection Reflect what the client
has said in an exaggerated way. This encourages
the client to argue less, and can elicit the
other side of the client's ambivalence.

• Client My smoking isn't that bad.
• HCP There's no reason at all for you to be
  concerned about your smoking. (Note it is
  important to have a genuine, not sarcastic, tone
  of voice).

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Double-sided reflection Acknowledge both sides
of the client's ambivalence.

• Client Smoking helps me reduce stress.
• HCP On the one hand, smoking helps you to reduce
  stress. On the other hand, you said previously
  that it also causes you stress because you have a
  hacking cough, have to smoke outside, and spend
  money on cigarettes.

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Metaphor Painting a picture that can clarify the
clients position

• Client Everyone keeps telling me I have a
  drinking problem, and I dont feel its that bad.
• HCP Its kind of like everyone is pecking on you
  about your drinking, like a flock of crows
  pecking away at you.

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Shifting focus Provide understanding for
the client's situation and diffuse resistance
Client What do you know about quitting? You
probably never smoked. HCP It's hard to
imagine how I could possibly understand.
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Reframing Much as a painting can look
completely different depending upon the frame put
around it, reframing helps clients think about
their situation differently

• Client I've tried to quit and failed so many
  times.
• HCP You are persistent, even in the face of
  discouragement. This change must be really
  important to you.

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Emphasizing Personal Choice Reflect the
clients autonomy

• Client I've been considering quitting for some
  time now because I know it is bad for my health.
• HCP You're worried about your health and want to
  make different choices.

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Summarizing

• Special form of reflective listening
• Ensures clear communication
• Use at transitions in conversation
• Be concise
• Reflect ambivalence
• Accentuate change talk

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How Motivational Interviewing is Directive

• Selective eliciting questions
• Selective reflection
• Selective elaboration
• Selective summarizing
• Selective affirming

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Using OARS Micro-skills

• Eliciting Change Talk
• The idea in MI is to have the client present
  arguments for both sides in making changes. It
  is the interviewers task to facilitate the
  clients expression of such change talk. This is
  a process of shared decision-making, not an
  attempt to manipulate or sculpt the clients
  will.

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Listening For or Eliciting Change Talk

• Desire I want to I really like to I
  wish I can.
• Ability I would I am able to... I
  could I should
• Reason I think it would be good to Someone
  wants me to This is important
• Need I need to do this Equals
  Commitment Language

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Recognizing Readiness

• Diminished resistance
• Decreased discussion about the problem
• Resolve
• Change talk
• Questions about change
• Envisioning
• Taking steps

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Decisional Balance

• Ambivalence is a normal part of the change
  process
• Use ambivalence to promote positive change
• Weigh pros and cons of behavior
• Increase discrepancy

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DECISIONAL BALANCE SHEET
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Decisional Balance Exercise

• What are some of the good things about your ___
  (drinking, smoking, eating whatever you want)?
  What else?
• What are some of the not-so-good things about
  your ____? What else?

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Double-sided reflection Acknowledge both sides
of the patient's ambivalence.

• Patient Smoking helps me reduce stress.
• HCP On the one hand, smoking helps you to reduce
  stress. On the other hand, you said previously
  that it also causes you stress because you have a
  hacking cough, have to smoke outside, and spend
  money on cigarettes.

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Importance RulerHow important is it to you to
change your smoking habit?If 0 was not
important, and 10 was very important, what
number would you give yourself ?

• 0 1 2 3 4 5 6 7 8
  9 10

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Exploring Importance

• Why are you at x and not (x 2)? (always start
  with the higher number)
• (If 9 or 10) Thats great. Im curious why it is
  that important.
• What would need to happen for your importance
  score to move up from x to (x 2)?
• What stops you moving up from x to (x 2)?

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Confidence RulerHow confident are you that if
you wanted to change your smoking habit, you
could do so?If 0 was not confident, and 10
was very confident, what number would you give
yourself ?
0
1 2 3 4 5 6 7 8 9
10


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Building Confidence

• Im curious about your confidence. What makes it
  an x and not (x 2)?
• What would make you more confident about making
  these changes, what might move you from x to (x
  2)?
• How can I help you succeed?

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Building Confidence

• Is there anything you found helpful in any
  previous attempts to change?
• What have you learned from the things that went
  wrong last time you tried?
• If you were to decide to change, what might your
  options be?
• Are there any ways you know about that have
  worked for other people?

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Building Confidence

• What are some of the practical things you would
  need to do to achieve this goal?
• How could you put them into action?
• What, if anything, can you think of that would
  help you feel more confident?
•  
•  

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Eliciting and Strengthening Confidence (Ability)
Talk

• Evocative questions
• The confidence ruler
• Reviewing past successes
• Personal strengths and supports
• Brainstorming
• Giving information and advice
• Reframing
• Hypothetical change

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Responding to Confidence (Ability) Talk

• Reflecting
• Elaborating
• Summarizing
• Affirming
• Raising possible problems and challenges

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Readiness Ruler How ready are you at this
moment to change your smoking habit?If 0 was
not ready, and 10 was very ready, what number
would you give yourself ?


0
1 2 3 4 5 6 7 8 9
10
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Exploring Readiness

• Why do you give yourself an x and not (x - 2)
  (begin with the higher number)?
• What might make you even more ready to make a
  change?
• What would be your first step in making a change?

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• SIGNS OF READINESS FOR CHANGE
• Increased questions about change asks what they
  could do about the problem..
• Envisioning begins to talk about how life might
  be after a change..
• Experimenting begun by experimenting with
  possible change approaches (e.g., going to a
  support group, going without for a few days,
  reading/looking up information on the internet)..

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Evocative questions for obtaining change talk

• What concerns you about your drinking/smoking/heal
  th habit?
• What are others worried about regarding your
  drinking/smoking/health pattern?
• What relevance/importance does smoking/drinking
  have in your personal goals?
• If you decided to change your drinking/smoking/hea
  lth habit, how would that change your life? Your
  familys life?

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Negotiating a Change Plan

• Setting Goals
• Considering Change Options
• Arriving at a Plan
• Eliciting Commitment

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Negotiate a plan of action

• Invite active participation by the patient
• Patient determines goals priorities
• Patient weighs options
• Together, work out details of the plan

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Giving Information and Advice 3 Kinds of
Permission

• The person asks for advice
• You ask permission to give advice
• You qualify your advice to emphasize autonomy

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Giving information and advice

• Always ask for permission
• Other patients have found ___ to be of help.
  Are you interested in knowing about that or is
  there something we should discuss first?
• Offer alternatives (menu of options)
• We could give you a recommended diet or set up
  a session with a nutritionist.
• Provide more information according to the
  interest of the patient
• Would you like to know more about Weight
  Watchers?

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A SMART plan will allow evaluation of progress
Specific Measurable Achievable Relevant Time-
limited
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Finalizing the motivational interview

• Review the commitment
• Review the plan
• Set up a new time to meet
• Express encouragement

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The MI Shift

• From feeling responsible for changing clients
  behavior to supporting them in thinking talking
  about their own reasons and means for behavior
  change.

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References

• Burke BL, Arkowitz H, Menchola M. The efficacy of
  motivational interviewing a meta-analysis of
  controlled clinical trials. J Consult Clin
  Psychol 20037184361.
• Miller WR, Rose GS. Toward a theory of
  motivational interviewing. American Psychologist
  2009, 64, 527-537.
• Lai DTC, Cahill K, Qin Y, Tang J-L. Motivational
  interviewing for smoking cessation, Cochrane
  database of systematic reviews 2010, Issue 1.
  No CD006936. DOI 10.1002/14651858. CD006936.
  pub2.